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Teamwork, Hospitalists and Hospital Medicine

Teamwork is one of the most important elements in hospital medicine. And yet, it continues to be one of the greatest challenges and roadblocks to improved patient outcomes. There are numerous reasons. First, hospitals are complex organizations, requiring interaction from a number of people – often under tense and life-threatening circumstances. Second, teamwork training is limited, both in medical school and in acute care settings. While most people agree that teamwork is necessary for positive outcomes, little time is carved away for actual team training. There simply isn’t enough time in the day to take care of patients and conduct team-building exercises.

Hospitalists are at the center of any discussion about teamwork.

Not only must they bridge the work of specialists, consultants and other care providers, but they must try to work with the patients themselves as a care coordination team. They are often juggling multiple and overlapping roles, both as a team “leader” and as part of an overall team of care. In other words, they must maneuver through and around an entire array of interpersonal relationships that are critical to the success of their patients’ care.

Researchers have long been interested in how hospitalists work within a total hospital medicine setting. For example, a group of researchers wanted to know what formal and informal strategies they used to “effectively enact teamwork and care coordination.”

To answer that question, the group conducted fieldwork in 2011 in which they observed the work of four hospitalists in three hospitals, closely studying the behavior of the group in their everyday context. While the overall sample was small, each setting was different, giving researchers a broad view of the physicians in action.

FORCES WORKING AGAINST TEAMWORK IN HOSPITAL MEDICINE

Here is what they found.

Not surprisingly, hospitalists had to face a number of different forces that worked against them to bring about care coordination. There were three primary drivers towards dysfunction.

First, a hospital’s spatial organization created a difficult environment for hospitalists to work closely with their teammates. They were often assigned patients located in different areas. In fact, observers found some circumstances where patients were located on every floor of the hospital. As a result, they often interacted with a different care team depending on the location of the patient.

Another problem for hospitalists revolved around multiple internal information systems. While electronic health records have improved the overall distribution of patient information, researchers found that some information was not recorded. In fact, they noted that in one instance, “no one record system captured all of the needed information around any one patient, nor did the formal systems show a complete picture. As a result, care coordination was not fully realized.

Another roadblock getting in the way of hospitalists achieving better care coordination revolved around uncoordinated teams, often the result of the loose coupling of units, services and professions within the hospital. This lack of interconnection, especially between professions and specialties made it difficult at times for the hospitalists to even determine who was on a patient’s “team.” As the researchers noted, when each hospital unit or specialty department assigned patients to a given provider for the day,  “these allocations were often not communicated to other groups or reflected in their record.” In fact, researchers also said that providers could go through at least some of their shift not knowing who else was on their patients’ teams for the day.

Finally, researchers noted that processes that were intended to be relatively automatic, such as ordering standard tests or procedures, were not very reliable in practice. As a result, hospitalists often had to resort to personal contacts and relationships to keep track of an order placed in the system. One example – during a handoff from the night to day shift, two hospitalists discussed a computerized tomography (CT) scan that should have been done overnight, but was not.

All of these roadblocks not only compound the challenges of building cohesive teams within a hospital setting, but they “pose serious threats to patient safety.”

COPING WITH TEAMWORK ROADBLOCKS

How did the hospitalists in this research cope?

For some, rounding became an important routine for team building. By establishing their physical presence throughout the hospital, these somewhat-predictable encounters helped establish dialogue and association with the various team members. Just “being there” was sometimes the most expeditious way to be the basic, necessary information about who else is caring for their patients.

Another way of bypassing the roadblocks was simply having local knowledge of the hospital’s diverse microsystems. This provided hospitalist with very practical ways to manage their patients’ care.

And finally, some hospitalists developed ad hoc systems of cataloguing their local knowledge. For example, one rounding physician carried a handwritten sheet of important phone numbers that she might need at any given time, information which was not readily available on any standard phone directory she could carry around.

In summary, navigating the many potholes and roadblocks associated with providing true care coordination and teamwork in hospital medicine requires stamina, ingenuity and strong interpersonal communication skills. Researchers confirmed that getting a team approach to work often requires the individual attitude of each physician, especially since the internal systems themselves often don’t advance the cause.

J Health Organ Manag. 2015;29(7):933-47. doi: 10.1108/JHOM-01-2015-0008.
How hospitalists work to pull healthcare teams together.
Chesluk B1, Bernabeo E, Reddy S, Lynn L, Hess B, Odhner T, Holmboe E.

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